Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Friday, May 03, 2013

health and medicine, continued

(In case you haven't picked up on it yet, I have embarked upon a long-form essay. It will continue.)

So what is “medical” attention? It is well known but seldom seen as remarkable that most societies known to history and anthropology, even small scale ones with limited hierarchy and division of labor, have cultural roles for specialists in healing people. In societies large enough to support full-time specialists, as far as I know there is always a full-time healing profession. In some times and places these people have also been more generalist priests, with additional assigned powers, and priests can always try to get you some divine intercession, but usually there is a secular healer role as well, or more than one. There are some systems in which shamans can heal or sicken, curse your enemies, make it rain, make your object of desire fall for you, or whatever. There’s certainly variety. But in Europe and its metastasis to North America, since classical antiquity, physicians and priests have been distinct, as they are now generally around the globe.

One reason I find this remarkable is that for most of history, almost everywhere in the world, these people couldn’t actually do much, if any, good, in most cases. They may have had some useful skills – to set broken bones, maybe to cut out or saw off rotting parts, perhaps out of their formulary of dozens or hundreds of concoctions a few were truly beneficial. But as we now know, most of what they did was at best useless, but often harmful, they best-known example being bloodletting. But it’s perhaps less widely recognized that, lacking any concept of pathogenesis, surgeons and obstetricians were probably the world’s leading source of infection, and thereby managed to kill innumerable patients and birthing women.

The scientific revolution that upended cosmology and physics starting in the 16th Century (Copernicus died in 1543, Newton in 1727) didn’t really get going in biology until the 19th Century, and even then it did not at first have a great deal to offer to medicine. Darwin obviously caused quite the brouhaha, but his theory was not immediately relevant to medical practice. Ignaz Semmelweis figured out the importance of hygienic practices, such as physicians washing their hands and instruments between patients, around 1850. But he didn’t have any scientific explanation for his observations, and he was generally scorned. Once Pasteur figured out about a decade later that microbes can cause disease, we were getting somewhere; surgery and childbirth became more hygienic by the end of the century, and Pasteur’s work also led to the development of vaccines in addition to the long-available cowpox inoculation against small pox. (That was based on empirical observation, with no explanatory theory.)

So, by the beginning of the 20th Century, medicine was doing less harm than before, but still couldn’t do much good. Effective treatments for the vast majority of human ills still did not exist. Just about anybody could open a medical school and confer a medical degree, and just about anybody did. Most of these schools were owned by one or two doctors, existed to make a profit, didn’t teach much science, if any, and had low requirements for entrance and degrees. There were many competing systems of thought about the nature and causes of ill health, almost all of them completely bunk, some of them unfortunately still with us, such as homeopathy.